=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114320488
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FREMONT, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2014
-----------------------------------------------------
Last Update Date | 10/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 909 FREMONT AVE
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-599-5335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 909 FREMONT AVE
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32789-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-599-5335
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | ARNOLD SANTOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-599-5335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3104A0625X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility (Mental Illness)
-----------------------------------------------------
License Number | AL 9198
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------